Provider Demographics
NPI:1760992697
Name:GONZALES, COLLEEN (LMSW)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25704
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-0704
Mailing Address - Country:US
Mailing Address - Phone:505-855-9893
Mailing Address - Fax:505-848-9468
Practice Address - Street 1:4700 COAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2804
Practice Address - Country:US
Practice Address - Phone:505-265-3711
Practice Address - Fax:505-848-9468
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-087851041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool